Employment Registration Number (ERN) - Application Form (Form A), ROASD-1769, Revision-0

Page No. Page 1 of 1 EMPLOYMENT REGISTRATION NUMBER (ERN) Form No. ROASD-1769 APPLICATION FORM – FORM A Revision No. 0 Effectivity June 22, 2026 PART A. GENERAL INSTRUCTIONS 1. Use this form to signify intent to apply Filipino and Foreign employees to secure an Employment Registration Number (ERN). 2. Changes in format are not allowed, and all fields should be properly filled out. 3. Dates must be encoded in month-day-year (Ex. April 30, 2026). 4. If the information required is not applicable, write "N/A". 5. All requirements should be submitted in digital copy. 6. Applications with incomplete information / requirements will not be accepted. PART B. REQUIRED ATTACHMENTS / SUPPORTING DOCUMENTS For Filipino Applicants: For Foreign Applicants: 1. PSA-certified birth certificate 1. Passport Bio page 2. Valid NBI Clearance 2.Valid National Police Clearance 3. Tax Identification Number (TIN) 3. Valid work visa and permit as provided by existing laws, rules, and regulations 4. 2x2 I.D. Photo (White Background) 4. Tax Identification Number (TIN) 5. Medical Certificate 5. 2x2 I.D. photo (White Background) 6. Medical Certificate PART C. APPLICATION DETAILS Date: Name of Company: Business / Site Address: # LAST FIRST MIDDLE BIRTHDAY DATE HIRED PASSPORT 9(G) VISA VISA (MM/DD/YYYY) NATIONALITY POSITION (MM/DD/YYYY) TYPE OF VISA TIN AEP NO. NUMBER NAME NAME NAME NUMBER VALIDITY 1 2 3 4 5 6 7 8 9 10 TOTAL: PART D. CERTIFICATION This is to certify that the information provided herein has been carefully verified and found to be updated, accurate and complete. I understand that misdeclaration and incorrect information may lead to imposition of administrative penalties. PART E. NAME OF DECLARANT (to be filled-up by Authorized Representative) Printed Name: Contact #: Position E-mail Add: Signature